Leg massage enables a directional influence on breathing as well as eye-to-eye contact between the woman and her partner

     The 1970s were a time of increased technological intervention in maternity care, with induction of labour, epidural anaesthesia and operative delivery becoming commonplace.¹
     Over the next 20 years attitudes began to change, giving more control to expectant parents.²
     Touch, in the form of a positive massage during labour, was an area I wanted to explore to determine whether it is a useful way of shifting the focus of active support away from the midwife and towards the birthing partner.
     The following report summarises a review I undertook of my practice of massage techniques in labour.³

Background
     Throughout the 17 years that I worked as a community midwife at the John Radcliffe Hospital, Oxford, I witnessed many changes in attitude and approach. During the 1970s it was common for doctors and midwives to take absolute control over childbearing women, leaving many women feeling disempowered and very dissatisfied with their experiences. Groups such as the NCT evolved in response and actively challenged this type of care,^4,5 emphasising the normality of childbirth.
     During the 1990s alternative and complementary therapies began to gain popularity. Books and courses became available on such topics as massage, aromatherapy, reflexology, homoeopathy and acupuncture.^6,7 There was a shift towards acceptance of complementary therapies, both by the users and the providers of health services. Guidance on the use of complementary therapies is given in the Midwife’s Code of Practice, and their use is to be based upon a sound knowledge and appropriate training.⁸
     Massage is one such complementary therapy. It is a form of touch, and as such is an important form of communication.
When performed in a positive and conscious way it can provide an active role for a support person. In investigating the physiological changes associated with touch, two small studies are of relevance.
     The first looked at the effects of massage on 11 preterm infants, and indicated that, while pain results in an increase of cortisol concentrations, the opposite occurs in response to massage.⁹
     The second study shows the effects of connective tissue massage and suggests that it results in a rise in beta endorphins.¹⁰

The needs of men
     Women and their partners, during the 1980s, were encouraged to play a greater part in their ‘birthing experience’ and couples became better informed.¹¹
     There has also been an emphasis on the importance of promoting options and choice for childbearing women and their partners.²
     Despite this, many men still do not feel part of the labour process.
     Some fathers have expressed a need for more support to achieve an active role within the labour experience.
One commentator has written to men:
     “You may be all too aware of the feeling of helplessness and frustration that you are not able to do enough to help your wife, especially with her pain in first stage.”¹²
     In a survey of fathers’ needs¹³ the men considered themselves as essentially helpless in supporting their partner with the pain.    Furthermore, two men out of the 30 in her survey “perceived health professionals as likely to increase the sense of powerlessness with which they viewed labour”.
     Another important finding of this survey is that men want an active role during labour “because doing something seems more controlling than doing nothing”.

Questions
     As a midwife, I used massage in labour, and the women found it both soothing and comforting. In addition, it gave me a positive, supportive role. I wanted to find out if I could pass this role on to the birthing partner; whether the partner could be more actively involved in the process of labour through the use of massage.
     I therefore decided to undertake a review of the use of massage in my practice. This took place over a ten-month period. My purpose was to clarify:
•    How best to implement massage for the woman, with her partner being the primary masseur;
•    How to help the couple become more reliant on each other and not focus entirely on the midwife for support;
•    How couples overall responded to this care option;
•    Whether any modifications of the specific massage techniques were called for;
•    Whether this programme would be of value in the future.

Participants
     During my employment as a community midwife at the John Radcliffe Hospital, I offered massage to women whom I attended antenatally; others were referred to me by my colleagues, and some were women I met in early labour. Altogether, 50 women and their partners were included in the review. All the couples were interested in learning the massage techniques and agreed to complete a questionnaire between two and five days after delivery.
     The questionnaire included closed and open questions and sought to gain information on their views of their preparation for labour, on their perception of massage for pain relief, the outcome of labour, the couples’ feelings about the labour and the effects of the massage.

Both partners completed the questionnaire.
     Women were not offered massage if they were ‘high risk’ (for example with hypertensive disorders), if they were anticipating a caesarean section, or if they were planning a waterbirth.

Massage in action
     At 36 weeks gestation onwards the participating women were asked if they wished to join the massage programme. The massage techniques taught were those described later in this article.
     Of the 30 nulliparous and 20 multiparous women to whom I taught the techniques, two were booked for home delivery. Two of the nulliparous women declined massage in labour (one of whom subsequently had an elective caesarean section). Overall, I was able to attend the labours of, and therefore observe the massage techniques of, 22 women, 12 of whom were nulliparous and 10 of whom were multiparous.

The effects of massage on labour
     The types of onset of labour, differentiated between the nulliparae and multiparae, are shown in Table 1. Augmentation of labour was noticeably higher in the nulliparous women.

     The uptake of analgesia by women employing the massage techniques is shown in Table 2.

Women’s views of the effects of massage
     Some of the comments which the women wrote on the questionnaire, on the effects of the massage techniques, were as follows (with the number of women who made the comments in brackets):
•    Helped to cope with pain (21 nulliparae,16 multiparae)
•    Helped with breathing (5 nulliparae,11 multiparae)
•    Useful/helpful in labour (23 nulliparae,42 multiparae)
•    Relaxing (1 nullipara, 1 multipara)
•    Gave control (1 nullipara)
•    Poor effect in advanced labour (2 nulliparae, 1 multipara)
•    Useful distraction (2 multiparae)
•    Gave sense of wellbeing (1 nullipara,1 multipara)
•    A positive contact (20 nulliparae,18 multiparae)
•    Invaluable (1 nullipara)
•    Reassuring (1 nullipara)
•    I would recommend it (1 nullipara, 2 multiparae)

     These comments suggest that the massage had positive effects, helping women to cope with pain and promoting a positive feeling of labour.

Coping with pain
     Specific comments made by the women about how massage helped them to cope with the pain of labour included:
“Very useful as a means of pain relief. Used for the first ten hours with breathing techniques as the sole means of relief. It proved very good and I feel it would have been possible to rely on massage, had I not failed to progress, for the entire labour” (nullipara).
     “In some ways (and this is very difficult to describe in words), the massage focused my attention on the pain, but at the same time gave me a way of coping with it. Previous to starting the massage, / had been walking around, almost as though trying to walk away from the pain. The massage was a way of facing up to it” (multipara).
     “Good for breathing, rhythm and a distraction from pain” (multipara).
     The effects of massage techniques in combination with the breathing appear to provide a focus for women which was a distraction from the pain.

Feeling in control and reducing anxiety
     The relationship between feeling anxiety, feeling in control and pain relief is sometimes difficult to tease apart, but the following quotes indicate that massage assisted some women in feeling in control of the pain of their contractions:
     “It helped me concentrate on the breathing, which helped me override the pain to the best of my ability, also made me feel in control to a certain degree” (nullipara).
     “I felt that the massage helped me to have more control of the pain. It also seemed to provide pain relief, as I compare contractions I went through without massage with those with the massage. I had no pain relief during my first labour and I found the massage during the second one a much more pleasant way of getting through it” (multipara).

Partners’ views on the use of massage techniques
     A summary of the comments made by the partners in using the massage techniques is given below:
•    Helped feeling of involvement (12 nulliparae, 7 multiparae)
•    Helpful/useful (9 nulliparae,10 multiparae)
•    Practical/positive contribution (7 nulliparae,1 multipara)
•    Active role (7 nulliparae,1 multipara)
•    Togetherness (1 nullipara)
•    Rewarding (1 nullipara)

Being involved in my partner’s labour
     Most partners found that using massage techniques assisted them in being involved and taking an active part in the process of labour. Some of the comments made include:
     “A significant effect. During the very early stage I felt uninvolved and unable to help – a bit of a ‘spare part’. When using massage, I felt very much more involved and glad that I was clearly having some impact in assisting pain relief” (partner of nullipara).
     “It enabled me to get more involved in an active way and contribute positively, to help my partner get through the contractions. If not for the massage, I would have held her hand, wiped her face, etc., all very useful, but this way I was able to help her get through the contractions directly” (partner of multipara).

Taking an active role in the birth
     The partners appeared to find it beneficial to take an active role. For some this increased their sense of sharing and involvement at this time:
     “The massage was a very positive aspect of my wife’s labour. I felt that I was making a practical contribution to the labour and as a result of this feel that I would take a different approach to massage as a form of pain relief in future” (partner of nullipara).
     “I felt usefully involved during labour, and looking back, feel that I had a part in the baby’s delivery” (partner of multipara).
     Partners who took an active role also felt a sense of taking part in the birth of the baby, and their positive contribution reduced their anxiety. The benefits of the partner undertaking the massage are not just the massage itself, but also the specific role they are provided with during labour.

Preparation for massage techniques
     Effective teaching of this type of massage needs to be done on a one-to-one basis, either antenatally or in early labour. Group teaching does not work well, as the women become inhibited when taking their clothes off to learn the techniques. Although the massage techniques in themselves are simple, it is necessary for the couples to practise them for it to work well. An hour taken to teach the partner is very worthwhile.
     I wanted to find out what women felt about their preparation for the massage. The majority of women appreciated the preparation antenatally and would have liked to have had the opportunity to learn massage techniques to use in pregnancy. Some responses to the preparation are given below
     “Invaluable – it would have been impossible and impracticable without” (nullipara).
     “Yes, I would have jumped at the chance (to use massage during pregnancy), to help with sleeping, relieving tension and general relaxation’ (nullipara).
     “Yes – essential!! Particularly synchronising massage and breathing” (multipara).
     “The more the better” (multipara).

Conclusion
     This review of my practice of massage suggests that it has a value in achieving positive physical and psychological effects. It may also have a role in reducing the amount of analgesia and promoting women’s ability to cope in labour. The positive responses from the partners were centred on their feeling involved and helpful. Massage will not always be a viable care option for everyone and the wishes of the individual to opt out of massage need to be respected. For those who are interested in massage, it is a positive way of giving the birthing partner an active role and therefore empowering the couple.
     These massage techniques offer one way of overcoming the helplessness felt by many men when they are with women in labour.

Massage techniques during labour
     What follows is a detailed description of the programme of massage techniques which I devised in response to the woman’s needs.
Specific massage techniques for labour
     The massage techniques used during the first stage of labour are specifically designed to support the woman with her breathing during contractions. The massage is therefore directional, reasonably firm and rhythmic. Back, leg and arm massage is taught together with the optimum positions to facilitate each of these. Hand and foot massage using circular strokes have no relationship to this breathing/relaxation approach and so are not included in this programme.
     It is important that the massage is started early in labour so that the couple can get used to working together with the massage and breathing. In the earlier part of the labour the masseur takes the lead from the woman. Likewise when the contractions get stronger and the woman is breathing more quickly, the masseur needs to follow. It is only at the decreasing stage of the contraction that the masseur takes over, slowing down the hand movements so as to help slow the breathing by the end of the contraction and create relaxation.

Circular hip massage
Purpose
     This massage is taught primarily for women experiencing back pain during their labour. However, it has also been found to be of use generally during labour.
     The firmness and repetition of this movement in the area of discomfort aims primarily to help relieve pain. In addition, women may be more able to regulate their breathing by focusing on the upward and downward strokes of the massage. This can help with relaxation.
Positions
     The woman has to be in a comfortable, relaxed position; what this is will change throughout the labour. The masseur also has to be in a comfortable position to utilise energy, convey calm and prevent injury.
     Either the woman kneels on the floor (or bed) leaning over a chair or against the head of the bed (or wall) and is supported by cushions or pillows. She can also be on all fours. The masseur kneels directly behind, leaving enough room for movement; or the woman stands with legs apart leaning over a table, against the wall or over a bean bag placed on a bed and the masseur sits on a chair or stool directly behind.
Massage
     Before the massage begins the masseur warms the base oil in his hands and applies to the area being massaged. Two hands are placed on either side of the spine in the sacral region with the hands pointing in an upward direction and not placed too far under the buttocks. This massage should never be done directly over the spine (Fig 1 & 2).

Figure 1

Figure 2

     When the contraction starts the woman is asked to breathe audibly so that the masseur can hear. The massage is essentially extremely simple but needs coordination between the woman and masseur. During inspiration the masseur’s hands go upwards as he leans forward. All pressure and energy comes from the body and is transmitted through the hands, which need to remain flexible and fluid.
     The hands massage up to waist level during the inspiration. Then during the start of expiration the fingers on both hands turn inwards and elbows turn outwards to massage outwards across the back to the hips (Fig. 3).
     The hands then move smoothly down the sides of the hips until they arrive at the starting position. This is done during expiration. The masseur must perform the whole move smoothly and firmly in time with the breathing and without losing contact with the woman (Fig. 4). These movements continue throughout the contraction.

Figure 3

Figure 4

Whole back massage
     At the end of the contraction the masseur leans further forward if kneeling or stands up if sitting and continues up the back (on either side of the spine) to the upper back, around the shoulders and down each side of the body to the starting point (Fig. 5).
     This final stroke can be repeated as many times as is wanted and women report that it is extremely relaxing following the contraction. This stroke is performed more slowly and gently, as it is not following any breathing pattern but rather aiding deeper relaxation.

Figure 5

Figure 6

Upper back/shoulder massage
     This massage can be performed to facilitate breathing and relaxation. The same technique is used as for the circular hip massage, but using the upper back (Fig. 6).

Sacral pressure massage for labour
     This massage can be used in combination with the circular hip massage at the end of the contraction when the hands return to the starting position, or on its own, depending on what the woman finds most useful at the time. It is done in the positions outlined for the circular hip massage and it follows the same principles: the massage is slow, rhythmic, firm and in time with the breathing. The masseur uses the palm of the hand over the sacral area and massages firmly, in a clockwise direction if using the right hand and anticlockwise if using the left hand (Fig. 7). The hand not being used to massage is supporting the woman either on the hip or shoulder (whichever feels more comfortable).
     The massage hand should remain flexible and fluid with all the pressure coming through the body.
     Some women find this massage very helpful if there is intense backache.

Figure 7

Figure 8

Lower circular back massage from the side
     The masseur performs this massage either standing or kneeling at the woman’s side. The optimum positions for the woman are standing, kneeling or on all fours. It can also be done when the woman is sitting, or lying down on her side but is not as easy and possibly not as effective. Only one hand is used. The starting point is the near side hip area, moving across the waist to the opposite hip. The action is done during inspiration (Fig. 8).
     The massaging hand moves down the side of the hip, the fingers around the curves, down to the buttock, then across and slightly upwards to the sacral area with the heal of the hand and finally back across the near side hip to the starting point (Fig. 9). This is done during expiration. This movement is continued throughout the contraction, with the hand that is not massaging supporting the near side shoulder area. At the end of the contraction the sacral pressure massage can be incorporated, if requested.

Figure 9

Figure 10

Leg massage
     During the investigator’s survey into the use of massage, it became apparent from feedback by the women that they felt ‘lost’ if the massage stopped during labour and they found that their breathing and relaxation did not work as well. The aim of the leg massage is not primarily to relieve pain, as women do not usually experience pain in their legs during a contraction, but rather to have a directional influence on their breathing. This may help them relax and may therefore indirectly help relieve pain. Some couples also commented that it is very helpful and reassuring to have eye-to-eye contact with each other, which can only happen with this technique. If the woman needs to sit down, e.g. to permit foetal heart monitoring, it is more difficult to continue with back massage, so a leg massage may be substituted. The leg massage is done with the woman sitting either on a chair or on the bed.
     The masseur kneels, stands or sits in front of the labouring woman and starts the massage on the inner side of each foot with elbows outward and fingers of both hands facing each other (Fig.10).
     As the contraction begins, the hands move up the inner part of the legs, with the masseur leaning up and forward. The movement continues to the top of the thigh and then around to the hip area. This is done during inspiration. As the leg is considerably longer than the lower back, the movement needs to be faster, ensuring that the smoothness and rhythm is maintained. The hands then move down each side of the outer leg arriving back at the starting point in time with the exhalation.
     This movement is repeated as many times as is necessary throughout the contraction, making sure that there is no loss of contact with the woman. The masseur has to make sure that he moves well during this massage otherwise strain to his back may result.
     If the masseur is kneeling to perform the massage then it is advisable to get up and move around in between contractions. If the contractions become stronger and the breathing faster, then it is not possible for the masseur to massage the full length of the leg. In this case the upper or lower portion of the leg massage is chosen, incorporating the rest of the leg as soon as the strength of the contraction starts to fade. This allows the masseur to slow down the massage and direct the woman back into her slower breathing rhythm.

Arm Massage
     This massage is used if it is impossible to massage the back or legs for example during a vaginal examination. It helps to keep the woman focused on her breathing, aiding relaxation and pain relief. It maintains reassuring contact during a possibly frightening experience (e.g. prior to forceps/ventouse delivery) and keeps the partner involved.
     The masseur stands to the side and holds the woman’s hand, supporting the wrist.
     The massaging hand goes up the inner arm to the shoulder, around and down the outer side of the arm back to the hand. As with all the other massages outlined, it works in combination with breathing; up on inspiration, down on expiration.

Conclusion
     The massage techniques described here encourage women and their partners to play a more active part in the birthing experience. While the importance of positive touch from the midwife cannot be overstated, these techniques are designed to give control to the couple, helping them to become more reliant on each other, instead of focusing entirely on the midwife for support.

References
1.    Tew M. Safer Childbirth. London: Chapman and Hall,1990.
2.    DoH Expert Maternity Group. Changing Childbirth (Cumberlege Report). London: HMSO,1993.
3.    Kimber L. Effective techniques for massage in labour. The Practising Midwife April 1998; 1: 4: 36-39.
4.    Inch S. Birthrights. London: Green Print,1989.
5.    Moorhead J. New Generations: 40 Years of Birth in Britain. London: National Childbirth Trust,1996.
6.    Tisserand R. Aromatherapy today – part I. The International Journal of Aromatherapy 1993; 5 (3): 26-29.
7.    Thomas R. National Occupational Standards for Alternative and Complementary Therapists. International Journal of Alternative and Complementary Medicine 1995; 13 (11): 23-26.
8.    UKCC. The Midwife’s Code of Practice, London: UKCC,1994.
9.    Acolet D. et al. Changes in plasma cortisol and catecholamine concentrations in response to massage in preterm infants. Archives of Disease in Childhood 1993, 68: 29-31.
10.    Kaada B, Torteinbo O. Increase of plasma endorphins in connective tissue massage. General Pharmacology 1989, 20: 4: 487-89.
11.    Balaskas A., Balaskas J. Active Birth Manifesto 1982.
12.    Brant H. Childbirth for Men. Oxford: Oxford University Press,1985; 125.
13.    Nolan M. Caring for fathers in antenatal classes. Modern Midwife 1994 Feb; 4(2): 25-28.

• This article was originally published in two parts in April and December 98 issues of The Practising Midwife (formerly Modern Midwife) published by Hockland and Hockland, 174a Ashley Road, Hale, Cheshire, WA15 9SF 0161-929 0929.